This study was conducted in 2012 in Gandaki Medical College Teaching Hospital (GMCTH), a tertiary care hospital located in the heart of Pokhara, western region of Nepal. Pokhara is a major tourist destination city in Nepal.

Eligible study participants included in this survey were those aged 18 years and over and those who are studying MBBS/Nursing in GMCTH or who were employees of GMCTH. Altogether, 750 adults were approached, and 515 participants agreed to participate and 500 participants including smokers and non-smokers, finished the survey. All participants were asked to complete a face-to-face interview by using a standard questionnaire; informed consents were sought prior to the conduction of interview . The study was approved by the ethical board of GMCTH. Verbal consent was obtained from each participant.

Information was obtained from all participants on their smoking status. Smoking status was measured by asking whether participants had ever smoked. Participants were grouped into three categories; non-smokers, smokers and former smokers.Smokers were defined as those who had smoked at least 100 cigarettes in their lifetime, and those who had smoked at least one cigarette per day at the time of the survey. Former smokers were defined as individuals who had quit smoking at least one month prior to the survey and those who had smoked at least one cigarette per day, prior to quitting. Those who did not meet the above criteria were labeled as non-smokers. Participants also reported their genders, ages, and education levels.

Nine warning labels (8 labels with both pictures and text and one with only text) were included in the interview questionnaire. They were coded as A-I. Label A was ‘Cigarettes cause cancer’ [Table/Fig-1]. Label B was ‘Cigarettes cause strokes and heart diseases’. Label C was ‘Tobacco smoke causes fatal lung disease in non-smokers’. Label D was ‘Tobacco smoke hurts babies’. Label E was ‘Tobacco smoking is addictive’, while Label F was ‘Smoking causes peripheral vascular diseases’. Label G was ‘Smoking is injurious to health’. Label H was ‘Quitting smoking greatly reduces serious risk to your health’. Label I was ‘Smoking can kill you’. All English health warnings were translated into Nepali during the interview. Only the Label G was the text warning in the side panel of the package, while other Labels included the pictorials and text information on the whole front face of the package.

[Table/Fig-1]:

Different warning label used for the study

By making reference to Labels A to I, participants were asked whether each label gave them clear information on the harm which cigarette smoking could cause on health and about the specific diseases that occurred in relation to cigarette smoking. Participants were also asked whether Labels A, B, C, D, E, F, H and I gave them clear information on specific diseases which smoking could cause (as has been described above).

Two questions on the perceived impact of giving cigarettes as a gift were asked. These included: 1) If you want to give cigarettes as a gift? do the following cigarette labels (A-I) make you change your mind ? 2) If you want to give cigarettes as a gift, which warning label is most likely to stop you from giving cigarettes as a gift?

Participants were asked two questions on the perceived impact of quitting smoking. These included: 1) If you were a cigarette smoker, would the following labels (A-I) make you want to quit smoking? 2) If you are a cigarette smoker, which warning label is most likely to cause you to quit?

Participants were asked if they knew that WHO FCTC and if Nepal had ratified. If they answered yes, participants were then asked whether they were aware of the FCTC requirement that health warnings on cigarette packaging should be large, clear, visible and legible.

Univariate and bivariate analyses were conducted to examine how much impact each of the different cigarette warning labels had and the knowledge on the FCTC by age groups, gender, education levels and smoking status. To compare the current Nepali label with international labels, Label A, B, C, D, E, F, H and I were aggregated into one group. Chi-square tests were used to assess differences among groups, wherever they were appropriate. All analyses were conducted by using SPSS, 20.0 (SPSS Inc., Chicago, IL, USA).

Eligible study participants included in this survey were those aged 18 years and over and those who are studying MBBS/Nursing or who were employees of GMCTH. A total of 500 participants (187 males and 313 females) were involved in the study. The average age was 22.0 ± 10.0 years. A higher proportion of males reported that they were current or former smokers as compared to females and 24.4% of participants had bachelor degrees from technical universities or even higher degrees. [Table/Fig-2] demonstrates the demographic characteristics of the sample.

Only 2.2% of the participants were aware of FCTC and 1.8% knew that Nepal had not ratified the FCTC. Furthermore, 1.4% knew the requirement of the FCTC, that health warnings on cigarette packings should be large, clear, visible, and legible.

The text plus graphic warning labels were judged to be more effective for prevention, motivation to quit and motivation to be absentees, and to be concerned about health effects.

Among the participants, 51.6% said that Label G provided least information on the of the cigarette while other all the text plus graphic labels provided more detailed and specific information on harm. Labels A-F, H and I gave adequate information on the harm of cigarette smoking, 69.0% for Label A, 70.2% for label B, 87.6% for label C, 95.4% for label D, 78.2% for label E, 90.6% for label F, 70.3% for label H, and 84.6% for label I. A higher proportion of participants said that as compared to label G, label D gave them clearer information on the harm of smoking across all the subcategories [Table/Fig-3].

Among the participants, 75.6% and 81.4% reported that they would not give cigarettes with Labels G and H (respectively) on the package as a gift to somebody. Over 90% of participants refused to give cigarettes as a gift if the package displayed warning Labels A, B and I. The proportion of those who would not give cigarettes as gift was higher among females, those who had never smoked and those who had higher educational levels. On comparing Label G with the combined labels, it was found that the proportion of respondents who would not give cigarettes as a gift was higher if any of Labels A-F and I were on the package [Table/Fig-4]. A majority of participants considered that Label G was least likely to stop them from giving cigarettes as a gift, while >90% participants considered that Label I was most likely to stop them from giving cigarettes as a gift.

34.4% and 19.6% of the participants reported thinking about quitting due to warning Label I and Label H, respectively. We asked non-smokers whether they were smokers, if the labels would impact on a decision to quit smoking. Non-smokers were more likely to quit smoking due to Labels H and I, in comparison to those who were smokers. It was seen that due to the warning on Label G, least participants were motivated to quite smoking, or to remain abstinent or to not start smoking [Table/Fig-5,6–7]. More than one third of participants (34.4%) considered that Label I was most likely to cause them to quit, to remain abstinent and to not start smoking.

[Table/Fig-5]:

Respondents choice on more effective level to quite the smoking

[Table/Fig-6]:

Respondents choice on more effective level to discourage people from starting smoking

[Table/Fig-7]:

Respondents choice on more effective level for not to smoke again

Of all the labels, text only label, “smoking is injurious to health” produced the least percentage (4%) of the panelists who reported that the label would make them least concerned about the health effects of smoking. In contrast, 27.6% said that the text plus graphic warning label, “smoking can kill you” would make them more worried about the health effects [Table/Fig-8].

Separate logistic regression models were used to compare text-only versus text-plus-graphic labels with regards to perceived effectiveness for discouraging people from starting to smoke (prevention); discouraging people from presenting cigarettes as gift; encouraging smokers to quit; motivating former smokers to remain abstinent; and level of concern about the health effects of smoking. The perceived effectiveness was much higher for the text-plus-graphic as compared to the text-only labels for prevention (odds ratio[OR]5.20; 95% confidence interval [CI] 2.82-9.60); discouraging people from presenting cigarettes as a gift (OR 2.31; 95% CI 1.65-3.25); encouraging smokers to quit (OR 4.73; 95% CI 2.60-8.59); motivating former smokers to remain abstinent(OR 5.65;95% CI 3.00-10.63); and concern about the health effects (OR 4.07; 95% CI 3.06-5.41).

The tobacco industry uses the tobacco package as a promotional opportunity.Public awareness is low about the true risks of tobacco use, even in countries with widespread anti-smoking campaigns [14]. Most smokers cannot recall the specific health effects associated with smoking [15]. Even smokers who understand the dangers of smoking underestimate the severity of its impact on health. Most smokers perceive other smokers to be at greater risk from smoking than themselves [16]. Smokers tend to be even less aware of the risks of secondhand smoke to others [17]. An understanding of both the risks and severity of smoking are important factors in motivating smokers to quit.

Public health proponents see the tobacco package as an educational opportunity.Warning labels have been found to inform smokers about the health hazards of smoking, encourage smokers to quit, and prevent nonsmokers from starting to smoke. Warning labels on tobacco products are an ideal way of communicating with smokers. Pack-a-day smokers are exposed to images printed on packs at least 20 times a day (and 7,000 times a year), when they buy and use cigarettes. That’s 20 opportunities a day for delivering anti-smoking messages at critical junctures: the point of purchase and the time of smoking. The use of pictorial images enhances the impact of the public health message [13]. Smokers sepotted that they receive more information about the risks of smoking from the tobacco product package than from any other source except television [18].

Given the reach and frequency of exposure, warning labels have the potential to have a significant impact on smoking behaviour. Further, two-thirds of all smokers indicate that the package is an important source of health information and health knowledge is strongly associated with an intention to quit smoking [19].

A major study which compared warning label data from four countries with widely varying labeling policies (Australia, Canada, the United Kingdom and the United States) found that that text-only labels (as seen in the U.S.) were associated with lower levels of awareness about the health risks of smoking as compared to prominent, pictorial warning labels (as seen in Canada and Australia). Furthermore, the study indicated that pictorial warning labels were more effective than text-only labels in leading people to think about quitting and deterring them from having a cigarette [15]. A follow-up investigation of the four-country study revealed that larger, pictorial warning labels were more likely to be noticed and rated as effective by smokers. Pictorial warning labels increased awareness about the association between smoking and specific health hazards (e.g., lung cancer, heart disease, stroke, impotence, etc) and were associated with increased quit attempts [20]. As more countries introduce stronger labels and evaluate their effectiveness, growing evidence shows that larger, bold and pictorial labels have an impact on awareness of the risks of tobacco use. Effective warning labels increase knowledge on risks associated with smoking and can persuade smokers to quit [19].

After Canada introduced large pictorial warning labels in 2000, 91% of smokers surveyed said they had read the warnings and were able to demonstrate a strong knowledge on the subjects the warnings covered. Smokers who had read and discussed the warnings were more likely to quit or make attempts to quit at the 3-months follow-up [13]. After Australia introduced pictorial warning labels in 2006, 63% of non–smokers and 54% of ex-smokers thought the new labels “would help in preventing people from taking up smoking [21].”

After Singapore introduced pictorial warning labels in 2004, a Health Promotion Board survey found that 28% of the smokers surveyed reported smoking fewer cigarettes because of the warnings; 14% of the smokers surveyed said that they made it a point to avoid smoking in front of children;12% said that they avoided smoking in front of pregnant women; and 8% said that they smoked less at home [22]. Since, Thailand introduced its second round of pictorial labels in 2006, 53% of smokers said the pictorial warning labels made them think “a lot” about the health risks and 44% of smokers said the warnings made them “a lot” more likely to quit over the next month [23].

A study on U.S. and Canadian adult smokers found that more graphic representations of health consequences evoked more fear and resulted in stronger intentions to quit smoking [24]. After Brazil introduced new pictorial warnings in 2002, 67% of smokers said the new warnings made them want to quit [25]. Brazil introduced a second round of labels in 2004. In a study which evaluated both rounds, researchers found that the most threatening and fear-arousing images on warning labels increased intention to avoid smoking [26]. A study in Canada (where large, pictorial pack warnings are required) suggested that reading and thinking about warning labels was positively associated with intention to quit smoking [13]. An investigation on the impact of the text-only Chinese labels as compared to other text and pictorial labels from around the world, found that larger pictorial labels were perceived to be more effective in informing about the dangers of smoking, convincing youth not to start, and motivating smokers to quit [27]. A Greek study on adolescents found that approximately 84% of non-smoking adolescents reported that the proposed EU pictorial labels were more effective than the old EU text labels in preventing initiation of smoking [28].

Strasser AA et al., found that graphic images on cigarette packages can help health warnings stick in people’s minds better, and improve their recall of the health warning. The 200 participants in this study were current smokers, aged 21–65 years, who reported smoking a minimum of ten cigarettes a day for at least five years. Participants could not mode to attempt to quit at the time of the study. This study did not test whether remembering health warnings more accurately translated into the desired effect of making a person quit smoking. Therefore, this study alone cannot justify whether graphic warning labels on cigarette packs really “work better” than written warnings when it comes to quit rates [29].

In our study, pictorial warning label, ‘smoking can kill you’ significantly drew the attention of the participants, that strongly agreed with findings of most of the studies. Our study provides strong evidence that perhaps the most effective way of conveying health risks to smokers is using graphic, large and comprehensive warning labels. Our study also suggested that picture warnings that include graphic, fear-arousing depictions of smoking’s effects on the body are the most effective, because they are associated with increase in motivation to quit smoking, thinking about health risks and engaging in cessation behaviour.

As of June 2011, 44 countries and jurisdictions in the Americas, Eastern Mediterranean, Europe, South-East Asia and Western Pacific regions passed legislation which asked for pictures or images on cigarette packs. A European Union directive gave its 27 member countries, the option of adding pictures to warnings as a way of educating smokers on the risks of continuing to smoke. It is time for government of Nepal to follow the WHO FCTC protocol in the cigarette packages, for the displaying of pictorial warning labels for promoting smokers to quit and discouraging non smokers from starting to smoke. These actions will reflect the growing consensus that warning labels are effective at communicating health messages and discouraging tobacco use.

The findings of this study support previous research that has found that text-plus graphic warning labels are more salient and potentially more effective than text-only labels. Pictorial warning labels counter tobacco industry advertising on tobacco products, increase knowledge about risks associated with tobacco use, reduce adolescents’ intentions to smoke, and motivate smokers to quit. Stronger warnings on cigarette packages need to be part of a larger Nepalese public health educational effort. It is time for Government of Nepal to adopt stronger pictorial warnings on cigarette packages.

This article was aimed at observing the difference of perception of students and staff of a tertiary care medical college towards different pictorial warning labels vs text labels on cigarette packages. It may not reflect the community, since all the participants were literate. A majority of the participants in the institute were non-smokers and the smokers and non-smokers could not be compared.